Careers Application for Employment

Part 1. Personal Details Surname: - First Name(s): Title: Mr. Mrs. Miss. Ms. Other (please specify) Address: - Postcode: Telephone: - Email address:*(required)

Part 2. Eligibility to work in the UK and National Insurance Number Are you eligible to work in the UK? Yes No (Note: If you are invited for interview, you will be asked to bring in evidence of your eligibilty to work in the UK) National Insurance Number: - Note: All applicants will be required to bring proof of nationality (passport or birth certificate) to interview.

Part 3. Vacancy details Position applied for: - Area Applied for:

Part 4. Your work experience Please tell us about your work experience starting with your most recent employer. Name and address of employer Position held Period of employment Month/Year Salary Job Title and Key responsibilites Reason for leaving From To Amount of notice required at current position

Part 5. Qualifications – Education and Training Please tell us about your relevant qualifications, including NVQ's etc. Qualifications/Level Subject Grade/Result Date Year/Month

Part 6. Skills which demonstrate your ability or aptitude for this position.

Part 7. Equal Opportunities At Scrivens Opticians, a policy of monitoring job applications is maintained so that we can see whether satisfactory proportions of persons of both sexes, married persons and persons of different racial groups apply, and are given equal opportunity, for consideration for vacant jobs. As part of this monitoring policy, please complete the following information. Position applied for: Area: Are you: Male Female Are you: Married Single Widowed/Divorced - Ethnic Origin: Black African Black Caribbean Indian Pakistani Bangladeshi Chinese Irish White Other (please specify) Age: Under 30 30-45 45 or over If you consider yourself disabled (see part 8 of this form), are there any special facilities needed to attend interview?

Part 8. Disability Discrimination Act 1995 We wish to ensure that disabled people are not discriminated against, either directly or indirectly, both in recruitment/selection and in employment. If you are selected for interview and you consider yourself to be disabled, we may contact you to find if there are any particular arrangements you may need for the interview. You are not obliged to answer the following questions or to give details. As defined by the Act – a disability is a "physical or mental impairment which has a substantial and long-term adverse affect on a person's ability to carry out normal day-to-day activities". Do you consider yourself to be disabled? Yes No If yes, please give details:

Part 9. Driving Licence Do you hold a full current driving licence? Yes No Has your licence ever been withdrawn? Yes No A copy of your driving licence will be required for company records.

Part 10. Data protection By providing the information contained within this application form, you are consenting for its' use for the purpose of processing your application, assessing your performance in the future (should your application be successful) and monitoring the efficiency of our recruitment and other employment procedures.

Part 11. CRB/ISA Do you hold a current CRB/ISA Certificate? Yes No

Part 12. Declaration by applicant – Please read carefully before submitting Have you ever been convicted of a criminal offence that is not spent under the the Rehabilitation of Offenders Act 1974? Yes No If yes, please give details: I declare that the statements I have made on this application form are to the best of my knowledge true and complete. I understand that the Company reserves the right to withdraw any offer of employment or to terminate any employment already commenced if the information given by me is inaccurate or misleading in any way. * Please ensure you entered a valid email address in part 1 before submitting this form.